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Measuring Performance in the Medicare Drug Benefit

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  1. Measuring Performance in the Medicare Drug Benefit Third Annual Medicare Congress October 17, 2006 Laura Cranston, RPh www.PQAalliance.org

  2. The New Kid on the Block (PQA) • What are our predecessors doing? • AQA, HQA and others • What are their successes?

  3. Measuring and documenting quality is the new buzz in healthcare • How does MTM give us the opportunity to improve quality and measure our performance as RPhs—is this our launching point? • PQA will be the “consensus vehicle” for the development of measures to continue to facilitate the recognition of pharmacists’ role and value in improving patients’ outcomes and leading us to new models for patient care services

  4. President Bush’s Executive OrderAugust 22, 2006 “We’re all about being cost-conscious, said HHS Secretary, It’s just the American way. We clip coupons. We check for bargain flights on the Web. We carefully research new purchases. But when it comes to health care, we lack the tools to compare either quality or costs.”

  5. What the Executive Order says: • The order directs the agencies (HHS, Defense Dept, Veterans Affairs and Personnel Management), to: • Use, where available, health information computer systems that can talk to each other. • Enact programs that measure the quality of care, and develop those measures with the private sector and other govt. agencies • Make available to beneficiaries the prices that agencies pay for common procedures.

  6. The Executive Order • Develop and identify practices that promote high-quality care. • The order does not detail how health care providers would pay for increased costs related to establishing and meeting data-sharing standards or how providers would show charges for specific services. • John Engler, NAM stated, “Greater transparency of cost and performance information will help consumers make more informed choices.”

  7. HHS Secretary, Michael Leavitt • “ Very few people have a clue what their health treatments cost. And even fewer understand the quality that they’re receiving as it relates to other alternatives. The consequence of that is that you have a system where, essentially, there are no limits, and no one has an idea of what it’s costing.”

  8. Proven Value of Pharmacist Services In treating patients with high cholesterol Overall, Project ImPACT achieved a 22.1% reduction in LDL cholesterol and a 14% increase in HDL cholesterol, which translates to a potential stroke or heart attack reduction of 30 to 40%.

  9. Proven Value of Pharmacist Services In helping to manage patients with diabetes • Results for Diabetic Patients • $3,042 per patient per year saved • 50 percent decrease in sick leave for employees enrolled in program • In 2001 dollars, reduction of 58% in health care costs

  10. We know that pharmacists ARE providing valuable services, saving overall HC Dollars? • How do we document the interventions consistently? • How do we aggregate data across and within pharmacy settings? • How do we “report out” that data?

  11. Why PQA?Dr. Mark McClellan, Administrator, CMS: “While the primary goal of PQA will be to develop strategies for defining and measuring pharmacy performance,” he also expects that “this could lead to new pharmacy payment models for optimizing patient health outcomes.” Dr. McClellan indicated that his agency is “very interested in supporting the testing and development of such models.”

  12. Dr. Mark McClellan “For 40 years, Medicare and Medicaid have focused on paying the bills, without really taking into account whether what we are buying makes beneficiaries’ health care better.” “The result is that too often we focus on controlling costs only by reducing payment rates – rather than paying more for the best care.”

  13. PQA’s Mission Statement Improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring performance at the pharmacy and pharmacist-levels; collecting data in the least burdensome way; and reporting meaningful information to consumers, pharmacists, employers, payors, and other healthcare decision-makers to help make informed choices, improve outcomes and stimulate the development of new payment models.

  14. PQA’s Structure Membership-based Alliance Steering Committee Two Workgroups 1. Workgroup on Quality Metrics a) with subcommittee on LTC b) nine different Cluster Groups 2. Workgroup on Reporting

  15. Cluster Groups • Diabetes • Hypertension • Hyperlipidemia • Respiratory • Heart Failure • Patient Satisfaction • Patient Safety • Generic Efficiency Measures • Medication Adherence/Possession Ratios

  16. The Process: developing quality measures is a science • Conduct an environmental scan of healthcare measures that exist in the marketplace • Are existing measures recognized/endorsed by National Quality Forum? (NQF is the good house keeping seal of approval for quality measures) • Determine whether existing quality metrics can be modified, as determined by the Workgroup on Quality Metrics • Define and delineate a “gaps analysis.”

  17. The Challenges in Developing a Starter Set of Measures • Consensus on what is a “quality measure” • Do generic efficiency measures or formulary management belong in a starter set of measures? • How does a pharmacy or pharmacist document performance for any of the measures developed? • What will a demonstration project look like that tests these measures in today’s marketplace? • How will a RPh/pharmacy be paid for “performance”?

  18. The Challenges (continued) • Will these starter set of measures be applied to Medicare PartD beneficiaries only? • Are these measures only applicable to PartD beneficiaries who qualify for an MTM session?

  19. Examples of the Work of the Cluster Groups • Hyperlipidemia is a group that AMCP has been involved with, Heidi Lew is Chairing. • Examples of the types of measures under development: • The group recommends that medication persistence by measured at the timeframes of 6 and 12 months. The group recommends that both these timeframes be tested in the pilot program. • Persistence will be defined as continuation of therapy without a gap between fills of greater then “x” number of days. • Persistence on hyperlipidemia treatment shall be reported monthly (following the initial 6 months of the program, by each pharmacy), reporting the percentage of patients that meet the persistence criteria at 6 months and 12 months following their initial hyperlipidemia prescription.

  20. A Look at another PQA Cluster Group:Patient Satisfaction • The Patient Satisfaction Cluster Group has developed a sample Patient Satisfaction Survey for PQA. • The types of questions proposed include: • 1. Did a RPh discuss your medications with you? • 2. Did the RPh explain things in a way that was clear and understandable? • 3. Rate: How well the pharmacists instructs you about how to take your medications. • 4. Rate: The pharmacist’s efforts to help you improve your health or stay healthy.

  21. What next? • Measures and measures concepts will be presented to PQA’s full membership on November 20, 2006 • Once consensus is achieved, measures need to be validated in pharmacies. • Following validation of measures, CMS will take some of the PQA starter set and use these measures in a demonstration project • PQA will also look for others to use these same measures in other populations, and other plans.

  22. Heading Down the Right Path for Pharmacy/RPhs: What will it take? • Developing quality measures and having them adopted by federal, state, and private health plans will lead us to a better model • A model that is health outcomes-oriented/patient-service oriented vs. a product/commodity business model • Approaching the necessary change strategically

  23. PQA…how to become involved • www.PQAalliance.org • info@PQAalliance.org • Contact 703-690-1987 Laura Cranston